RESPIRATORY Flashcards
(343 cards)
1
Q
PNEUMONIA
Define pneumonia
A
Inflammation of the substance of the lungs .
It is an acute lower respiratory tract infection
2
Q
PNEUMONIA
Briefly describe the pathophysiology of pneumonia
A
- invasion and overgrowth of a pathogen in lung parenchyma
- overwhelming of host immune defences
- production of intra-alveolar exudates
3
Q
PNEUMONIA
what are the risk factors?
A
- extremes of age (elderly + young children)
- preceding viral infection
- immunosuppression
- IVDU
- respiratory conditions e.g. asthma, COPD, malignancy, CF
4
Q
PNEUMONIA
Name 3 pathogens that can cause community acquired pneumonia (CAP)
A
- Streptococcus pneumoniae (most common)
- Haemophilus influenzae
- s.aureus
5
Q
PNEUMONIA
which bacteria is associated with causing pneumonia in COPD patients?
A
h.influenzae
6
Q
PNEUMONIA
Name 3 pathogens that can cause hospital acquired pneumonia (HAP)
A
mainly gram negative
- Pseudomonas aeruginosa
- E.coli
- Staphylococcus aureus
7
Q
PNEUMONIA
which bacteria is associated with aspiration pneumonia?
A
klebsiella pneumoniae
8
Q
which pathogen can cause pneumonia in immunocompromised patients
A
pneumocystis jiroveci
9
Q
PNEUMONIA
what are the symptoms?
A
- productive cough
- pleuritic chest pain
- dyspnoea
- fever
10
Q
PNEUMONIA
what symptom is classically seen in klebsiella pneumoniae infection?
A
red current jelly sputum
11
Q
PNEUMONIA
what are the signs?
A
- reduced breath sounds
- bronchial breathing
- coarse crepitations
- hypoxia
- tachycardia
- pyrexia
12
Q
PNEUMONIA
what are the investigations?
A
CXR - repeated 6 weeks later to confirm resolution
BLOODS - FBC, U&Es, CRP
SPUTUM CULTURE
13
Q
PNEUMONIA
How can you assess the severity of community acquired pneumonia?
A
CURB65 score (1 point for each)
14
Q
PNEUMONIA
what are the components of CURB-65?
A
- Confusion
- Urea (>7 mmol/L)
- Respiratory rate (> 30/min)
- BP (<90/60 mmHg)
- Age >65
15
Q
PNEUMONIA
what do the scores for CURB-65 mean?
A
Scores
0-1 = mild (outpatient treatment)
2 = admit to hospital
3-4 = severe, admit and monitor closely
5 = ITU transfer
16
Q
PNEUMONIA
How can pneumonia be prevented?
A
polysaccharide pneumococcal vaccine - protests against 23 serotypes
Smoking cessation
17
Q
PNEUMONIA
What is the treatment for someone with mild CAP (CRUB65 score 0-1)?
A
oral amoxicillin at home
18
Q
PNEUMONIA
What is the treatment for someone with moderate CAP (CRUB65 score 2)?
A
consider hospitalising, amoxicillin (IV or oral) + macrolide (clarithromycin)
19
Q
PNEUMONIA
What is the treatment for someone with severe CAP (CRUB65 score 3-5)?
A
consider ITU,
IV Co-Amoxiclav + macrolide (clarithromycin)
20
Q
PNEUMONIA
what is the management of HAP?
A
low severity = oral co-amoxiclav
high severity = broad spectrum abx (IV tazocin or ceftriaxone)
21
Q
PNEUMONIA
What is the treatment for someone with Legionella pneumoniae?
A
Fluoroquinolone + clarithromycin
22
Q
PNEUMONIA
What is the treatment for someone with Pseudomonas aeruginosa pneumonia?
A
IV ceftazidime + gentamicin
23
Q
PNEUMONIA
Give 3 potential complications of pneumonia
A
- Respiratory failure
- Hypotension
- Empyema
- Lung abscess
24
Q
BRONCHIECTASIS
Define bronchiectasis
A
Chronic infection of the bronchi/bronchioles leading to permanent dilation and thinning of the airways
25
BRONCHIECTASIS
Describe the pathophysiology of bronchiectasis
Failed mucociliary clearance and impaired immune function means microbes easily invade and cause infection
This causes inflammation and progressive lung damage
Bronchitis --> bronchiectasis --> fibrosis
26
BRONCHIECTASIS
What can cause bronchiectasis?
1. Congenital = Cystic fibrosis
2. Idiopathic (50%)
3. Post infection - (most common)
- pneumonia,
- TB,
- whopping cough
4. Bronchial obstruction
5. RA
6. Hypogammaglobulinaemia
27
BRONCHIECTASIS
Which bacteria might cause bronchiectasis?
1. Haemophilus influenza (children)
2. Pseudomonas aeruginosa (adults)
3. Staphylococcus aureus (neonates often)
28
BRONCHIECTASIS
what are the symptoms of bronchiectasis?
1. Chronic productive cough
2. Purulent sputum
3. Intermittent haemoptysis
4. Dyspnoea
5. Fever, weight loss
29
BRONCHIECTASIS
what are the signs of bronchiectasis?
1. Finger clubbing
2. Coarse inspiratory crepitate (crackles)
3. Wheeze
4. rhonchi (low-pitched snore-like sound)
30
BRONCHIECTASIS
what are the investigations?
CXR - dilated airways with thickened walls (tram-tracks)
High resolution CT (gold standard) - bronchial dilation + wall thickening
sputum cultures
FBC
spirometry - obstructive pattern (FEV1/FVC <70%)
31
BRONCHIECTASIS
what spirometry pattern is found in bronchiectasis?
obstructive
FEV1/FVC <70%
32
Describe the treatment for bronchiectasis
1st line
- treat underlying cause
- chest physio
- annual flu vaccine
- antibiotics ofr exacerbations
2nd line
- mucoactive agent (carbocisteine)
- bronchodilator
- nebulised isotonic/hypertonic saline
- long term antbiotics (azithromycin)
long term oxygen
33
BRONCHIECTASIS
Give 3 possible complications of Bronchiectasis
1. Pneumonia
2. Pleural effusion
3. Pneumothorax
34
CYSTIC FIBROSIS
Describe the pathogenesis of Cystic fibrosis
Autosomal recessive defect in chromosome 7 coding CFTR protein (F508 deletion = most common mutation)
- Cl- transport affected
- Decreased Cl secretion and increase Na reabsorption this causes an increase H2O reabsorption --> thickened mucus secretion
- in the lungs, this leads to dehydrated airway surface liquid, mucus stasis, airway inflammation and recurrent infection
- this leads to progressive airway obstruction and bronchiectasis
35
CYSTIC FIBROSIS
What are the main systemic consequences of CF?
Pancreatic insufficiency = dehydrated secretion --> enzymes stagnation
GI = intraluminal water deficiency --> concentrated bile
Resp = thick mucus can't be cleared --> infection risk and inflammatory damage
36
CYSTIC FIBROSIS
How is CF passed on?
Autosomal recessive condition
37
How does neonate present with CF?
- Failure to thrive
- Meconium ileus - bowel obstruction due to thick meconium
- Rectal prolapse
- prolonged jaundice
38
CYSTIC FIBROSIS
How do children/young adults present with CF?
- Cough and wheeze
- Recurrent infections
- Haemoptysis
- Pancreatic insufficiency
- Malabsorption
- Male infertility
39
CYSTIC FIBROSIS
What are 3 possible respiratory complications of CF?
1. Pneumothorax
2. Respiratory failure
3. Cor pulmonale
4. Bronchiectasis
40
CYSTIC FIBROSIS
Give 3 signs of CF
1. Clubbing
2. Cyanosis
3. Bilateral coarse crepitations
41
CYSTIC FIBROSIS
Name 3 associated conditions with CF
1. Osteoporosis
2. Arthritis
3. Vasculitis
42
CYSTIC FIBROSIS
What investigations might you do to diagnose cystic fibrosis?
heel prick test (Guthrie test) - newborns at 5 days old
Sweat test = Na and Cl < 60 mmol/L
Genetic screening for common mutations
Faecal elastase - tests pancreatic enzyme function
Absent vas deferent and epididymis (males)
Microbiology - for infections
Spirometry
43
CYSTIC FIBROSIS
What is the management of the respiratory component of CF?
AIRWAY CLEARANCE
BRONCHODILATOR
- salbutamol
MUCOACTIVE AGENTS
- 1st line = rhDNase
- 2nd line = hypertonic saline +/- mannitol powder +/- rhDNase
- 3rd line = orkambi (lumacaftor + ivacaftor)
IMMUNOMODULATION
- 1st line = azathioprine
- 2nd line = oral corticosteroids
ANTIBIOTICS
44
CYSTIC FIBROSIS
how does orkambi work?
- LUMACAFTOR - increases number of CFTR proteins transported to cell membranes
- IVACAFTOR - potentiates CFTR proteins on cell surface, increases chance channel will open
45
CYSTIC FIBROSIS
what is the management for the GI/liver component of CF?
NUTRITION
- high calorie, high-fat diet
- vitamin A, D, E + K supplementation
- pancreatic enzyme replacement (Creon)
- PPI
DIABETES
- screen for diabetes annually from age 10
46
CYSTIC FIBROSIS
Infection with a gram negative bacteria is a particular concern in patients with CF. What is this organism and how can infection be prevented?
- Pseudomonas Aeruginosa
| - Nebulised anti-pseudomonal antibiotic therapy and regular sputum cultures
47
LUNG CANCER
Malignant bronchial tumour can be divided into 2 groups, what are they?
1. Non small cell lung carcinoma (80%)
| 2. Small cell lung carcinoma (20%)
48
LUNG CANCER
What type of malignant bronchial tumour tends to have a worse prognosis?
Small cell lung carcinomas - often metastasise
49
LUNG CANCER
From what cells are small cell carcinomas derived from and what is the significance of this?
Neuroendocrine cells
| Can secrete peptide hormones - ACTH, PTHrP, ADH, HCG
50
LUNG CANCER
Give the cell types the make up non-small cell lung cancers
1. Adenocarcinoma (40%) - originate from mucus-secreting glandular cells
2. Squamous cell (20%) - arise from epithelial cells + associated with keratin production
3. Large cell
4. carcinoid tumours
51
LUNG CANCER
what are the risk factors of lung cancer
1. Smoking = main cause
2. Asbestos
3. Radon exposure
4. Coal products
5. pulmonary fibrosis
6. HIV
7. genetic factors
52
LUNG CANCER
Which type of NSCC is most common in smokers?
Squamous cell carcinoma - it is most stronlgy associated with cigarette smoking
53
LUNG CANCER
Which type of malignant bronchial tumour fits into TNM staging?
Non small cell carcinoma
54
LUNG CANCER
What does TNM stand for in lung cancer?
T = size/invasion = T1 (<3cm) --> T2 (>3cm) --> T3 (chest wall/diaphragm) --> T4 (heart + vessels)
N = nodal involvement = N1 (hilar) --> N2 (ipsilateral mediastinal) --> N3 (contralateral mediastinal)
M = metastases = M0 (no metastases) --> M1 (metastases)
55
LUNG CANCER
where does lung cancer commonly metastasise to?
1. Bone
2. Brain
3. Lymph nodes
4. Liver
5. Adrenal
56
LUNG CANCER
which cancers most commonly metastasise to the lungs?
breast
bowel
kidney
bladder
57
LUNG CANCER
Give 4 symptoms of local disease lung cancer
Persistent cough
Shortness of breath
Haemoptysis
Weight loss
pleuritic chest pain
fever
night sweats
lethargy
58
LUNG CANCER
Give 4 symptoms of lung cancer that has metastasised
1. Bone pain
2. Headaches
3. Abdominal pain
4. Seizures
5. Neuro deficit - Confusion
6. Weight loss
59
LUNG CANCER
What are paraneoplastic syndromes?
they are conditions which occur as a side effect of the tumour and occur in 10% of patients
60
LUNG CANCER
Give examples of paraneoplastic syndromes due to lung cancer
- ↑PTH -> Hyperparathyroidism
- ↑ADH -> SIADH
- ↑ACTH -> Cushing’s disease
- lambert-eaton myasthenic syndrome
61
LUNG CANCER
Name 3 differential diagnosis's of lung cancer
1. Oesophageal varices
2. COPD
3. Asthma
4. Pneumonia
5. Bronchiectasis
62
LUNG CANCER
What investigations might you done on someone to determine whether they have lung cancer?
First line:
- CXR - central mass, hilar lymphadenopathy, pleural effusion
(a negative CXR does not rule out cancer)
- CT chest, liver & adrenal glands (gold standard) - for staging
- Sputum cytology - malignant cells in sputum
(high specificity but mixed sensitivity)
diagnostic = biopsy + histology
63
LUNG CANCER
What is the treatment for NSCLC?
NON-METASTATIC
- surgery (lobectomy/pneumonectomy) + adjuvant chemotherapy
- curative radiotherapy alternative to surgery
METASTATIC
- palliative treatment
- immunotherapy, chemotherapy + radiotherapy (generally has poor response to chemo)
64
LUNG CANCER
What are the contraindications to surgery in NSCLC?
- frail
- metastatic disease
- malignant pleural effusion
- SVC obstruction
- tumour near hilum
- vocal cord paralysis
65
LUNG CANCER
What is the treatment for SCLC?
Limited disease = chemo (cisplatin) + radio
Extensive = palliative chemo + care
* Superior vena cava stent + radiotherapy + dexamethasone for superior
vena cava obstruction
* Endobronchial therapy - used to treat symptoms of airway narrowing:
66
LUNG CANCER
Give 4 possible complications of lung cancer
1. SVC obstruction
2. ADH secretion --> SIADH
3. ACTH secretion --> Cushing's
4. Serotonin secretion --> carcinoid
5. Peripheral neuropathy
6. Pathological fractures
7. Hepatic failure
67
ASTHMA
Describe asthma
Chronic, inflammatory condition, causing episodes of reversible airway obstruction, due to:
Bronchoconstriction
Excessive secretion production
68
ASTHMA
what are the risk factors for asthma?
- history of atopy
- family history
- allergens (tobacco smoke, pets, outdoor air pollution, weeds, grass, pollen and dust mites)
- viral URTI
- cold weather + exercise
- occupational triggers (spray paint, flour etc)
69
ASTHMA
What 2 categories can asthma be divided into?
1. Allergic asthma (extrinsic), atopic, IgE and mast cell involvement
2. Non allergic asthma (intrinsic)
70
ASTHMA
Define atopy
The tendency to develop IgE mediated response to common aeroallergens
71
ASTHMA
What is allergic asthma?
When an innocuous allergen triggers an IgE mediated response
Immune recognition processes are faulty --> increase IgE, IL3,4,5, production
72
ASTHMA
What is non-allergic asthma?
Airway obstruction induced by exercise, cold air and stress
it is associated with both smoking/non-smoking
it is also associated with obesity
73
ASTHMA
Name 4 factors that can exacerbate asthma
1. Allergens
2. Viral infection
3. Cold air
4. Exercise
5. Stress
6. Cigarette smoke
7. Drugs - NSAIDs/BB
74
ASTHMA
What occupations can be associated with an increase risk of developing asthma?
1. Paint sprayers
2. Animal breeders
3. Bakers
4. Launder workers
75
ASTHMA
What other atopic conditions are associated with asthma?
Eczema
| Hayfever
76
ASTHMA
What are the clinical features of asthma?
SYMPTOMS
- episodic SOB
- diurnal variation (worse at night)
- dry cough
- wheeze + chest tightness
- history of exposure to trigger
SIGNS
- diurnal PEFR variation
- dyspnoea + expiratory wheeze
- Samter's triad (nasal polyps, aspirin sensitivity + asthma)
77
ASTHMA
What are the signs of an acute asthma attack?
1. Can't complete sentences
2. HR > 110 bpm
3. RR > 35/min
4. PEF < 50% predicted
78
ASTHMA
What are the signs of a life threatening asthma attack?
1. Hypoxia = PaO2 <8 kPa, SaO2 <92%
2. Silent chest
3. Bradycardia
4. Confusion
5. PEFR < 33% predicted
6. Cyanosis
79
ASTHMA
Give 3 differential diagnosis's of asthma
1. COPD
2. Bronchial obstruction
3. Pulmonary oedema
4. Pulmonary embolism
5. Bronchiectasis
80
ASTHMA
What investigations might you do someone to determine whether they have asthma?
- Spirometry with reversibility testing (>5 years) = Obstructive pattern:
- FEV1 <80% of predicted normal (reduced)
- FVC = normal
- FEV1/FVC ratio <0.7
- Peak flow rate - diurnal variation
- FeNO = >40 is positive
- CXR
- Atopy = skin prick, RAST
- Bloods = high IgE, Eosinophils
81
ASTHMA
What is the long-term guideline mediation regime for asthma?
1. low dose ICS/formoterol combination inhaler (AIR therapy) or if very symptomatic start low dose MART
2. low dose MART
3. moderate dose MART
4. check FeNO + eosinophil level (if either is raised, refer to specialist).
- If neither are raised = LTRA or LAMA in addition to moderate dose MART
- if still not controlled, stop LTRA or LAMA and try other drug option (LTRA/LAMA)
5. refer to specialist
82
ASTHMA
what is the management of a severe/life-threatening asthma exacerbation?
- oxygen
- nebulised bronchodilator (salbutamol)
- corticosteroid (40-50mg prednisolone)
- ipratropium bromide
- IV magnesium sulfate
- IV aminophylline
83
ASTHMA
what is the management of a moderate exacerbation of asthma?
- salbutamol
- 5 days oral prednisolone
84
ASTHMA
Give 3 possible complications of asthma
1. Exacerbation
2. Pneumothorax
3. Pneumonia
85
COPD
Define COPD
Progressive obstructive disorder (FEV1/FC < 70%) that is irreversible
long-term deterioration in air flow through the lungs, caused by damage to lung tissue (almost always due to smoking)
86
COPD
What can COPD be sub-divided into?
1. Chronic bronchitis
| 2. Emphysema
87
COPD
What is the clinical diagnosis of chronic bronchitis?
Cough/sputum for >3 months in 2 consecutive years
88
COPD
Describe the pathophysiology of chronic bronchitis
Airway inflammation --> fibrosis and luminal plugs --> decreased alveolar ventilation
89
COPD
Would a patient with chronic bronchitis be a 'pink puffer' or a 'blue bloater'?
Blue bloater
Patient have low PaO2 and high PaCo2 --> cyanosis --> cor pulmonale
Cyanosis = blue
90
COPD
Describe the pathophysiology of emphysema
Dilation and destruction of the lung tissue distal to the terminal bronchioles
Enlarged alveoli + loss of elastic recoil = increased alveolar ventilation
91
COPD
Would a patient with emphysema be a 'pink puffer' or a 'blue bloater'?
Pink puffer
Breathless but not cyanosed
Type 1 respiratory failure
Normal or near normal PaO2 and normal or low PaCO2
92
COPD
What are the main cells responsible for inflammation in COPD?
Neutrophils and macrophages
93
COPD
What type of T cell is involved in COPD?
CD8+
94
COPD
What can cause COPD?
1. Genetic = alpha 1 antitrypsin deficiency
2. Smoking = major cause
3. Air pollution
4. Occupational factors = dust, chemicals
95
COPD
Name 4 symptoms of COPD
1. Dyspnoea
2. Cough +/- sputum
3. Expiratory wheeze
4. Weight loss
5. SOB
96
COPD
Give 4 signs of COPD
1. Tachypnoea
2. Barrel shaped chest
3. Hyperinflantion
4. Cyanosis
5. Pulmonary hypertension
6. Cor pulmonale
97
COPD
Give 3 differential diagnosis's for COPD
1. Asthma
2. HF
3. Pulmonary embolism
4. Bronchiectasis
5. Lung cancer
98
COPD
What investigations might you do to diagnose someone with COPD?
Spirometry = FEV1:FVC < 0.7
CXR = hyperinflation, bullae, flat hemi-diaphragms, large pulmonary arteries
CT = Bronchial wall thickening, enlarged air spaces
ECG = RA and RV hypertrophy
ABG = decreased PaO2 +/- hypercapnia
99
COPD
Give 3 factors that can be used to establish a diagnosis of COPD
1. Progressive airflow obstruction
2. FEV1/FVC ratio < 0.7
3. Lack of reversibility
100
COPD
What are the treatments for COPD?
general:
- stop smoking (refer to cessation services)
- pneumococcal vaccine
- annual flu vaccine
step 1:
- SABA (salbutamol or terbutaline) or SAMA (ipratropium bromide)
step 2:
- If no asthmatic / steroid response:
- LABA (salmeterol)
- LAMA (tiotropium)
- If asthmatic / steroid response:
- LABA (i.e. salmeterol)
- ICS (i.e. budesonide)
step 3:
- long term oxygen therapy
101
COPD
Give 3 advantages and 1 disadvantage of using ICS in the treatment of COPD?
Advantages
1. Improve QOL
2. Improve lung function
3. Reduce the likelihood of exacerbations
Disadvantages:
1. There is an increased risk of pneumonia
102
COPD
Give 3 possible complications of COPD
1. Exacerbations
2. Infection
3. Respiratory failure
4. Cor pulmonale
5. Pneumothorax
103
COPD
Define exacerbation of COPD
An acute event characterised by worsening symptoms beyond normal day to day variation
104
COPD
Give 2 potential consequences of exacerbations of COPD/asthma
1. Worsened symptoms
2. Decreased lung function
3. Negative impact of QOL
4. Increased mortality
5. Huge economic cost
105
COPD
What is the likely cause for an exacerbation of COPD?
Viral URTI
| Bacterial infections
106
COPD
What is the treatment for an exacerbation of COPD?
MILD
- managed in community
- increased salbutamol
- oral antibiotics
- 5 day course prednisolone
MODERATE
- hospital admission
- nebulised bronchodilators (salbutamol/ipratropium bromide)
- IV antibiotics
- steroids
- oxygen
SEVERE
- hospital admission
- non-invasive ventilation (BiPAP)
- nebulised bronchodilators (salbutamol/ipratropium bromide)
- IV antibiotics
- steroids
- oxygen
107
COPD
Give 3 ways in which subsequent exacerbations of COPD can be prevented
1. Smoking cessation
2. Vaccination
3. LABA/LAMA/ICS
108
PLEURAL EFFUSION
Give 3 functions of pleura
1. Allows movement of the lung against the chest wall
2. Coupling system between the lungs and chest wall
3. Clearing fluid from the pulmonary interstitium
109
PLEURAL EFFUSION
What does the pleural fluid contain?
Protein - albumin, globulin, fibrinogen
| Mesothelial cells, monocytes and lymphocytes
110
PLEURAL EFFUSION
How much fluid is contained within the healthy pleural space?
15ml
111
PLEURAL EFFUSION
What produces and reabsorbs pleural fluid?
Parietal pleura
112
PLEURAL EFFUSION
Name 3 diseases associated with the pleura
1. Pleural effusion
2. Pneumothorax
3. Pleural plaques
113
PLEURAL EFFUSION
Define pleural effusion
Excess accumulation of fluid in the pleural space
114
PLEURAL EFFUSION
Name the types of pleural effusion
1. Transudate (fluid leaks from vasculature)= extravascular fluid with low protein content (<25 g/L)
2. Exudate (inflammation impairs drainage of pleural fluid = protein rich fluid (>35 g/L)
3. Chylothorax = lymph in pleural cavity
115
PLEURAL EFFUSION
what are the causes of a transudate pleural effusion?
fluid movement (systemic causes)
1. Heart failure
2. fluid overload
3. Peritoneal dialysis
4. Constrictive pericarditis
5. hypoproteinaemia
- cirrhosis
- hypoaluminaemia
- nephrotic syndrome
116
PLEURAL EFFUSION
Name 3 causes of a exudate pleural effusion
inflammatory (local causes)
1. Pneumonia
2. Malignancy
3. TB
4. pulmonary infarction
5. lymphoma
6. mesothelioma
7. asbestos exposure
8. MI
117
PLEURAL EFFUSION
How does a pleural effusion present?
- SOB especially on exertion
- Dyspnoea
- Pleuritic chest pain
- dry cough
- Loss of weight (malignancy)
SIGNS
- Chest expansion reduced on side of effusion
- In large effusion the trachea may be deviated away from effusion
- Stony dull percussion note on affected side
- Diminished breath sounds on affected side
- Decreased tactile vocal fremitus (vibration of chest wall when speaking)
- Loss of vocal resonance
118
PLEURAL EFFUSION
what are the signs of pleural effusion?
- reduced chest expansion
- tracheal deviation
- Stony dull percussion note on affected side
- Diminished breath sounds on affected side
- Decreased tactile vocal fremitus
- Loss of vocal resonance
119
PLEURAL EFFUSION
what are the investigations for pleural effusion?
1st line: CXR (PA +/- lateral) =
blunt costophrenic angles, fluid in lung fissures, tracheal and mediastinal deviation
USS - identify pleural fluid
aspiration (thoracentesis/pleural tap)
- purulent = empyema (pus)
- turbid (cloudy) = infected
- milky = chylothorax
120
PLEURAL EFFUSION
what criteria can be used to distinguish between transudate and exudate effusions?
lights criteria
121
PLEURAL EFFUSION
How would you treat a pleural effusion?
- treat the underlying cause
- thoracocentesis for symptom management
- if infective, chest tube draining is required
122
PLEURAL EFFUSION
What can you do if recurrent pleural effusions occur?
Pleurodesis (stick pleura together)
indwelling pleural catheter
123
PNEUMOTHORAX
What is a pneumothorax?
Accumulation of air in the pleural space which can lead to partial or complete lung collapse
124
PNEUMOTHORAX
How can pneumothorax be classified?
- Spontaneous pneumothorax
- Traumatic pneumothorax
- Iatrogenic pneumothorax
- Tension pneumothorax
125
PNEUMOTHORAX
what is the a primary spontaneous pneumothorax?
spontaneous rupture of a subpleural bleb
126
PNEUMOTHORAX
what are the risk factors for a primary spontaneous pneumothorax?
- tall, slender, young
- smoking
- marfan syndrome
- rheumatoid arthritis
- family history
- rheumatoid arthritis
- driving or flying
127
PNEUMOTHORAX
what is a secondary spontaneous pneumothorax?
rupture of damaged pulmonary tissue
128
PNEUMOTHORAX
what are the risk factors for secondary spontaneous pneumothorax?
- underlying lung disease e.g. COPD, asthma, lung cancer
- TB
- pneumocystis jirovecii
129
PNEUMOTHORAX
How does a pneumothorax present?
- Sudden onset dyspnoea
Sudden onset pleuritic chest pain
- sweating
130
PNEUMOTHORAX
what are the signs of a pneumothorax?
- tachycardia
- tachypnoea
- cyanosis
- hyperresonance ipsilateral
- reduced breath sounds ipsilateral
- hyperexpansion ipsilateral
- contralateral tracheal deviation
131
PNEUMOTHORAX
What investigation might you do in someone you suspect to have a pneumothorax?
1st line - CXR = translucency and collapse
ABG = in dyspnoeic patients check for hypoxia
Gold standard = CT chest (rarely done in clinical practice)
132
PNEUMOTHORAX
What is the treatment for a primary pneumothorax?
PRIMARY
- small (<2cm) + asymptomatic = consider discharge
- if >2cm or breathless = aspirate with 16-18G needle
- if successful consider discharge + follow-up
- If unsuccessful insert chest drain + admit
133
PNEUMOTHORAX
what is the management for a secondary spontaneous pneumothorax?
SMALL (1-2cm)
- aspirate with 16-18G needle
- admit with high flow oxygen
LARGE (>2cm) or breathless
- insert chest drain
- admit with high flow oxygen
134
PNEUMOTHORAX
where is the needle for aspiration of a spontaneous pneumothorax placed?
- 2nd intercostal space midclavicular line
135
PNEUMOTHORAX
where are chest drains placed?
5th intercostal space mid-axillary line
136
PNEUMOTHORAX
what is the surgical management?
- surgical chemical pleurodiesis
- VATS pleurectomy
- open thoracotomy + pleurectomy
137
PNEUMOTHORAX
what are the indications for surgical management?
- 2nd ipsilateral pneumothorax
- 1st contralateral pneumothorax
- bilateral spontaneous pnemothorax
- persistent air leak after 5-7 days chest drain
- pregnancy
- at risk profession e.g. pilots + divers
138
PNEUMOTHORAX
Name a possible complication of a pneumothorax
Tension pneumothorax
139
TENSION PNEUMOTHORAX
Describe the pathophysiology of a tension pneumothorax
Pleural tear creates 1 way valve - air only goes into cavity --> increased unilateral pressure --> respiratory distress, shock and cardiac arrest
140
TENSION PNEUMOTHORAX
what are the risk factors?
- mechanical ventilation
- traumatic chest injury
- chest line insertion
- lung biopsy
141
TENSION PNEUMOTHORAX
What is the treatment for a tension pneumothorax?
Put out cardiac arrest call
Start high flow O2
Insert 14G needle at 4/5th intercostal space mid-axillary line
insert chest drain
142
INTERSTITIAL LUNG DISEASE
Define interstitial lung diseases
Distant cellular infiltrate and extracellular matrix deposition in lung distal to the terminal bronchioles - disease of the alveolar/capillary interface
143
INTERSTITIAL LUNG DISEASE
What are 5 major categories of interstitial lung disease
1. Associated with systemic disease - rheumatological
2. Environmental aetiology - fungal, dusts
3. Granulomatous disease - sarcoidosis
4. Idiopathic - idiopathic pulmonary fibrosis
5. Other
144
INTERSTITIAL LUNG DISEASE
What are the 4 major features of interstitial lung disease?
1. Cough
2. Dyspnoea
3. Restirictve spirometry
4. Abnormal CXR/CT
145
INTERSTITIAL LUNG DISEASE
Would pulmonary function tests taken from someone with interstitial lung disease show a restrictive or obstructive pattern?
Restrictive
| Decreased gas transfer and a reduction in PaO2
146
INTERSTITIAL LUNG DISEASE
What is the pathology of interstitial lung disease?
Increased fibrous tissue within the lung parenchyma resulting in increased stiffness and decreased expansion
147
SARCOIDOSIS
What kind of disease is sarcoidosis?
Granulomatous disease - type of interstitial lung disease
It is defined by presence of non-caseating granulomas
148
SARCOIDOSIS
Describe the pathophysiology of sarcoidosis
Chronic inflammation --> non-caseating granuloma in various body sites
thought to be due to type VI hypersensitivity reaction
149
SARCOIDOSIS
Describe the epidemiology of sarcoidosis
Women > men
Aged 20-40 years old
African-Caribbean
150
SARCOIDOSIS
what are the symptoms?
- non-productive cough
- gradual onset dyspnoea
- polyarthralgia
- uveitis (red eye, photophobia)
- fever
- fatigue
- weight loss
151
SARCOIDOSIS
what are the signs?
- cervical + submandibular lymphadenopathy
- lupus pernio (lupus-type rash)
- erythema nodosum (dusky coloured nodules on shins)
152
SARCOIDOSIS
What is the effect of sarcoidosis on the skin?
erythema nodosum (dusky coloured nodules on shins)
153
SARCOIDOSIS
What is the effect of sarcoidosis on the eyes?
Uveitis (red eyes + photophobia)
154
SARCOIDOSIS
What is the effect of sarcoidosis on the bone?
polyarthralgia
155
SARCOIDOSIS
What is the effect of sarcoidosis on the liver?
Hepatosplenmeagly
156
SARCOIDOSIS
What investigations might you do in someone who you suspect to have sarcoidosis?
BLOODS
- Raised inflammatory markers
- raised serum calcium
CXR
- hilar lymphadenopathy
- bilateral infiltrates
Chest CT
- ground glass appearance
SPIROMETRY
- restrictive (FEV1/FVC >0.8)
157
SARCOIDOSIS
How can you stage sarcoidosis?
Using CXR
Stage 1 = bilateral hilar lymphadenopathy (BHL)
Stage 2 = pulmonary infiltrates with BHL
Stage 3 = pulmonary infiltrates without BHL
Stage 4 = progressive pulmonary fibrosis, bulla formation and bronchiectasis
158
SARCOIDOSIS
How do you treat sarcoidosis?
asymptomatic non-progressive = observation
symptomatic or progressive = 1st line - corticosteroids, 2nd line - immunosuppressants
159
SARCOIDOSIS
Give 2 possible differential diagnosis's for sarcoidosis
1. Lymphoma
| 2. Pulmonary TB
160
IDIOPATHIC PULMONARY FIBROSIS
What is idiopathic pulmonary fibrosis?
Progressive fibrosis in the alveoli that limits the patients ability to respire
Formation of scar tissue in lungs with no known cause.
161
IDIOPATHIC PULMONARY FIBROSIS
Describe the pathophysiology of idiopathic pulmonary fibrosis
repetitive injury to the alveoli epithelium causes wound healing mechanisms to become uncontrolled
this leads to fibroblast over-production and increased fibrosis
this leads to a loss of elasticity and ability to perform gas exchange is impaired -> restrictive lung disease and progressive respiratory failure
162
IDIOPATHIC PULMONARY FIBROSIS
what are the risk factors of idiopathic pulmonary fibrosis?
- cigarette smoking
- infectious agents - CMV, Hep C, EBV
- occupational dust exposure
- drugs - methotrexate, imipramine
- GORD
- genetic predisposition
163
IDIOPATHIC PULMONARY FIBROSIS
what are the clinical features of idiopathic pulmonary fibrosis
1. non-productive cough
2. SOB on exertion
3. Systemic = malaise, weight loss, arthralgia
4. Cyanosis
5. Finger clubbing
6. bibasal crackles (Inspiratory crackles/crepitus)
7. dyspnoea
164
IDIOPATHIC PULMONARY FIBROSIS
What investigations might you do in someone you suspect to have idiopathic pulmonary fibrosis?
Bloods = raised CRP, immunoglobulins and check autoantibodies
CXR/CT = degreased lung volume + honeycomb lung
High resolution CT = ground glass appearance
Spirometry = restrictive
Lung biopsy = confirmation
ABG = type 1 respiratory failure
165
IDIOPATHIC PULMONARY FIBROSIS
What is the treatment for idiopathic pulmonary fibrosis?
SUPPORTIVE CARE
- pulmonary rehab
- long term oxygen
- pneumonia + flu vaccines
ANTI-FIBROTIC AGENTS
- pirifenidone
- nintedanib
LUNG TRANSPLANTATION
166
IDIOPATHIC PULMONARY FIBROSIS
what are the possible complications of idiopathic pulmonary fibrosis
1. Respiratory failure
| 2. Cor pulmonale
167
PULMONARY HYPERTENSION
Define pulmonary hypertension
A disease of the small pulmonary arteries characterised by vascular proliferation and remodelling. It results in a progressive increase in pulmonary vascular resistance (PVR)
Increase in mean pulmonary arterial pressure >25 mmHg and secondary right ventricular failure
168
PULMONARY HYPERTENSION
What can cause an increase in mPAP?
Increase resistance to flow
| Increased flow rate
169
PULMONARY HYPERTENSION
what are the causes of pulmonary hypertension
- pre-capillary
- multiple small PE's
- left-to-right shunts
- primary
- capillary
- emphysema
- COPD
- Post-capillary
- backlog of blood causes secondary hypertension
- LV failure
- chronic hypoxaemia
- living at high altitude
- COPD
170
PULMONARY HYPERTENSION
what is the clinical presentation of pulmonary hypertension
- progressive breathlessness
- exertional dizziness/syncope
- fatigue
- haemoptysis
171
PULMONARY HYPERTENSION
what are the signs?
- right parasternal heave
- loud 2nd heart sound
- pulmonary or tricuspid regurgitation
- raised JVP
- signs of underlying condition
172
PULMONARY HYPERTENSION
What are the investigations?
Initial tests:
- CXR - Enlarged main pulmonary artery, enlarged hilar vessels and pruning.
- ECG - right ventricular hypertrophy, right axis deviation, right atrial enlargement. (A normal ECG does not rule out the presence of significant pulmonary hypertension)
- TTE - (trans-thoracic echocardiogram)
Diagnostic test: Right heart catheterisation
173
PULMONARY HYPERTENSION
Describe the treatment of pulmonary hypertension
1st line
- CCBs
- pulmonary vasodilators e.g. prostacyclin, sildenafil
- diuretics
- oxygen therapy
- anticoagulation (warfarin or NOAC)
2nd line
- lung transplant
- balloon atrial septostomy
174
PULMONARY HYPERTENSION
Give a possible complication of pulmonary hypertension
Cor pulmonale (RS HF) --> pleural effusion + death
175
TB
what are the features of mycobacterium tuberculosis bacteria?
- Aerobic, non-motile, non-sporing, slightly curved bacilli with a thick waxy capsule
- Acid-fast bacilli – turns red/pink with Ziehl-neelsen stain
- Slow growing
- Resistant to phagolysosomal killing and able to remain dormant
176
TB
What mycobacterium can cause abdominal tuberculosis?
Mycobacterium bovis
| - found in unpasteurised milk
177
TB
How is TB transmitted?
Aerosol transmission
178
TB
Describe pulmonary infection of TB
Bacilli settle in lung apex
| Macrophages and lymphocytes mount an effective immune response that encapsulate and contains the organism forever
179
TB
Describe the pathogenesis of pulmonary TB disease
TB spread via respiratory droplets as it is an airborne infection
1. Alveolar macrophages ingest bacteria and the rods proliferate inside.
2. Drain into hilar lymph nodes 🡪 present antigen to T lymphocytes 🡪 cellular immune response.
3. Delayed hypersensitivity reaction 🡪 tissue necrosis and granuloma formation: caseating.
- Primary Ghon Focus
- Ghon Complex – Ghon focus + lymph nodes
180
TB
Describe the disease course of TB
Primary infection --> latent TB --> reactivation/immunocompromised
181
TB
Where in the lung is granuloma cavity most likely to develop in TB?
Apex of the lung = more air and less blood supply and less immune cells
182
TB
Give 3 risk factors for TB
1. Living in a high prevalence area
2. IVDU
3. Homeless
4. Alcohol
5. HIV +ve
183
TB
What systemic symptoms might you see as a result of TB?
1. Weight loss
2. Night sweats
3. Anorexia
4. Malaise
5. low grade fever
184
TB
What pulmonary symptoms might you see as a result of TB?
Productive cough
Haemoptysis
Cough >3 weeks (dry or productive)
Breathlessness
Sometimes chest pain
185
TB
Name 3 places where TB might spread to?
1. Bone and joint = pain and swelling
2. Lymph nodes = pain and discharge
3. CNS = TB meningitis
4. Biliary TB = disseminated
5. Abdominal TB = ascites, malabsorption
6. GU TB = sterile pyuria, WBC in GU tract
186
TB
What investigations might you do to determine whether someone has TB?
CXR = consolidation, collapse, pleural effusion
Microbiology - sputum/biopsy = Ziehl-Neelson stain and culture
187
TB
A special culture medium is needed to grow TB, what is it called?
Lowenstein Jenson Slope
188
TB
What test might you do to diagnose latent TB?
Tuberculin skin test (Mantoux)
Intradermal injection --> stimulates type 4 hypersensitivity reaction
interferon gamma release assay -> detect response of WBC to TB antigens
(rapid results and less likely to give false positives)
189
TB
What might a lymph node biopsy from someone with TB show?
Caseating granuloma
190
TB
What is the drug treatment commonly used for TB?
RIPE
RI = 6 months
PE = for first 2 months
R = rifampicin
I = isoniazid
P = pyrazinamide
E = ethambutol
191
TB
Give 2 potential side effects of Rifampicin
1. Red urine
2. Hepatitis
3. Drug interaction - it's an enzyme inducer
192
TB
Give 2 potential side effects of Isoniazid
1. Hepatitis
| 2. Neuropathy
193
TB
Give 2 potential side effects of Pyrazinamide
1. Hepatitis
2. Gout
3. Neuropathy
194
TB
Give a potential side effect of Ethambutol
Optic neuritis
195
TB
Why is compliance so important when taking TB medication?
Resistance and relapse likely if non-compliant
196
TB
Why does TB treatment need to last 6 months?
Ensure all dormant bacteria have 'woken up' and been killed
197
TB
Give 2 factors that can increase the risk of drug resistance in TB
1. If the patient has had previous treatment
2. If they live in a high risk area
3. If they have contact with resistant TB
4. If they have a poor response to therapy
198
TB
How can TB be prevented?
1. Active case finding
2. Detect and treat latent TB
3. Vaccination = BCG
199
WHOOPING COUGH
What is Whooping cough caused by?
Bordatella pertussis (gram -ve coccobacilli) - rod
200
WHOOPING COUGH
Describe the disease course of whooping cough
7-10 day incubation --> 1-2 week catarrhal stage --> 1-6 week paroxysmal stage
201
WHOOPING COUGH
What are the symptoms of whooping cough?
Paroxysmal cough - sudden and severe
| Vomiting after cough
202
WHOOPING COUGH
What is the treatment of whooping cough?
Clarithromycin - in catarrhal or early paroxysmal stages
- have little effect on disease course in paroxysmal stage
203
WHOOPING COUGH
How can you prevent whooping cough?
Pertussis vaccination
| 8, 12 and 16 weeks and a pre school booster
204
WHOOPING COUGH
Give 2 possible complications of whooping cough
1. Pneumonia
2. Encephalopathy
3. Sub-conjunctival haemorrhage
205
What is the difference between bronchitis and bronchiolitis?
```
Bronchitis = inflammation of bronchi epithelium due to irritant and chemical
Bronchiolitis = Inflammation of bronchioles and increased mucus secretion due to RSV infection
```
206
CYSTIC FIBROSIS
what is the epidemiology of cystic fibrosis?
* One of the most commonest lethal autosome RECESSIVE conditions in
CAUCASIANS, 25% condition and 50% carrier risk
- Much less common in Afro-Caribbean and Asian people
- Multi-system disease although respiratory problems are usually the most prominent
- Most people with CF also have pancreatic insufficiency
207
CYSTIC FIBROSIS
what are the risk factors for cystic fibrosis?
- Family history
| - Caucasian
208
CYSTIC FIBROSIS
what is CFTR and what is it's function?
* Transport protein on membrane of epithelial cells that acts as a chloride
channel
* Transports chloride ions
* Normally; it actively exports NEGATIVE IONS especially Cl- and Na+ passively follows causing an osmotic gradient and movement of water out of the cell and into the mucus
209
CYSTIC FIBROSIS
what is the clinical presentation of the alimentary effects of cystic fibrosis?
* Thick secretions
* Reduced pancreatic enzymes (due to mucus blocking pancreatic duct)
* Pancreatic insufficiency (diabetes mellitus & steatorrhoea (fatty stools
since enzymes not released to digest fat)
* Distal intestinal obstruction syndrome - bowel obstruction (equivalent of
meconium ileus) resulting in reduced GI motility
* Reduced bicarbonate (HCO3-)
* Maldigestion & malabsorption thus poor nutrition (associated with
pulmonary sepsis)
* Cholesterol Gallstones (in increased frequency) & cirrhosis
* Increased incidence of peptic ulcers & malignancy
210
PLEURAL EFFUSION
what is transudate pleural effusion?
- transparent (less protein)
* Pleural fluid protein is less than 30g/L since vessels are normal so only
fluid is able to leak out and not protein
* Occurs when the balance of hydrostatic forces in the chest favour the accumulation of pleural fluid i.e. increased pressure due to the backing up of blood in left sided congestive heart failure
211
PLEURAL EFFUSION
what is exudate pleural effusion?
- exudes proteins
- Pleural fluid protein is more than 30g/L since endothelial cells of vessels are more apart meaning fluid and protein is able to leak out
- Occurs due to the increased permeability and thus leakiness of pleural
space and or capillaries usually as a result of inflammation, infection or
malignancy
212
PLEURAL EFFUSION
what are the risk factors for pleural effusion?
- Previous lung damage
| - Asbestos exposure
213
PNEUMOTHORAX
what are the risk factors for pneumothorax?
Smoking
Family history
Male
Tall and slender build
Young age
Presence of underlying lung disease
214
PNEUMOTHORAX
what is the pathophysiology of pneumothorax?
Normally intrapleural pressure is negative
When there is a bridge between alveoli and pleural space or atmosphere and pleural space
Flow of air in until communication closed or gradient closed.
215
TENSION PNEUMOTHORAX
what is the clinical presentation of a tension pneumothorax?
Cardiopulmonary deterioration:
Hypotension – imminent cardiac arrest
Respiratory distress
Low sats
Tachycardia
Shock
Severe chest Pain
```
216
TENSION PNEUMOTHORAX
what are the clinical features of a tension pneumothorax?
Tracheal deviation to contralateral side
Ipsilateral reduced breath sounds
Hyperresonance on percussion
Hypoxia
217
PNEUMOTHORAX
what is the epidemiology of pneumothorax?
- Occurs spontaneously or secondary to chest trauma
- Spontaneous pneumothorax is most common in young males
- Generally a pneumothorax is MUCH MORE COMMON in MALES
- Often patients are tall and thin
- Caused by the rupture of a pleural bleb/sub-pleural bulla(serous filled blister),
usually apical (top) thought to be due to congenital defects in the connective
tissue of the alveolar walls
218
PNEUMOTHORAX
what are the causes of pneumothorax?
- In patients over 40 years of age the usual cause is underlying COPD
- Other/rarer causes include:
* Bronchial asthma
* Carcinoma
* Breakdown of a lung abscess leading to bronchopleural fistula
* Severe pulmonary fibrosis with cyst formation
* TB
* Pneumonia
* Cystic fibrosis
* Trauma (penetrating or rib fracture)
* Iatrogenic e.g. pacemakers or central lines
219
WHOOPING COUGH
what is the catarrhal phase of whooping cough?
* Patient highly infectious
* Cultures from respiratory cultures are positive in 90% of cases
* Malaise
* Anorexia
* Rhinorhoea (nasal cavity congested with significant amount of mucus)
* Conjunctivitis
220
WHOOPING COUGH
what is the paroxysmal phase of whooping cough?
* Begins 1 week later from catarrhal phase
* Coughing spasms
* Classic inspiratory whoop is only seen in younger individuals in whom
the lumen of the respiratory tract is compromised by mucus secretion
and mucosal oedema
* These coughing spasms usually terminate in vomiting
* Cough for more than 14 days
221
WHOOPING COUGH
what are the investigations for whooping cough?
- Chronic cough and one clinical feature indicated pertussis
- Chronic cough and history of contact or microbiological diagnosis is used
to confirm pertussis
- Suggested clinically by the characteristic whoop and history of contact with
an infected individual
- PCR test
- But culture of a nasopharyngeal swab = definitive diagnosis
222
what is the WHOOPINF COUGH
epidemiology of whooping cough?
Mainly a disease of childhood with 90% of cases occurring below 5 years of age
223
WHOOPING COUGH
what is the pathophysiology of whooping cough?
- Highly contagious and spread by droplet infection
| - In early stages it is indistinguishable from other upper respiratory tract infections
224
TB
what are the signs of TB?
```
Signs of bronchial breathing
Dullness to percuss
Decreased breathing
fever
crackles
```
225
PNEUMONIA
which bacteria causes rusty sputum in pneumonia?
strep pneumoniae
226
PNEUMONIA
what is atypical pneumonia?
Bacterial pneumonia caused by atypical organisms that are not detectable on Gram stain and cannot be cultured using standard methods.
227
PNEUMONIA
what are the common organisms that cause atypical pneumonia?
Mycoplasma pneumoniae,
Chlamydophila pneumoniae,
Legionella pneumophila
coxiella burnetii
228
TB
what is the mechanism of action for rifampicin for TB?
bactericidal - blocks protein synthesis
229
TB
what is the mechanism of action of isoniazid for TB?
bactericidal - blocks cell wall synthesis
230
TB
what is the mechanism of action for pyrazinamide for TB?
bactericidal initially, less effective later
231
what is the mechanism of action for ethambutol
bacteriostatic - blocks cell wall synthesis
232
BRONCHIECTASIS
what antibiotics are used for bronchiectasis?
- pseudomonas aeruginosa = oral ciprofloxacin
- h.influenzae = oral amoxycillin, co-amoxyclav or doxycycline
- staph aureus = flucloxacillin
233
GOODPASTURES SYNDROME
what is the pathophysiology of goodpasture's syndrome?
Specific autoimmune disease caused by a type II antigen-antibody reaction leading to diffuse pulmonary haemorrhage, glomerulonephritis (and often acute kidney injury and chronic kidney disease)
- There are circulating anti-glomerular basement membrane (anti-GBM) antibodies
234
COPD
what is the characteristic presentation of COPD?
```
productive cough
white or clear sputum
wheeze
SOB
following many years of smoking
```
235
LUNG CANCER
where does squamous cell carcinoma of the lung arise from?
- epithelial cells typically in the central bronchus
236
LUNG CANCER
what is squamous cell carcinoma associated with the production of?
associated with the production of keratin
237
LUNG CANCER
where does small cell lung cancer arise from?
Arises from endocrine cells typically in the central bronchus
238
LUNG CANCER
what is small cell lung cancer associated with the production of?
Secretes polypeptide hormones
239
LUNG CANCER
which is the most common lung cancer in non-smokers?
adenocarcinoma
240
LUNG CANCER
where does adenocarcinoma arise from?
mucus-secreting glandular cells
241
LUNG CANCER
which is more common, primary lung cancer or metastatic lung cancer from elsewhere?
Cancer metastasising from elsewhere is more common than a primary lung tumour
242
PULMONARY HYPERTENSION
what is the pathophysiology of pulmonary hypertension?
The main vascular changes are:
Vasoconstriction
Smooth-muscle cell and endothelial cell proliferation
Thrombosis
243
what are the investigations for IE COPD?
ABG
- CO2 retention → acidosis
- Raised pCO2 + low pO2 = T2RF
Chest X-Ray, sputum culture + sensitivities for antibiotic therapy, FBC + U&E
244
ASTHMA
what is the epidemiology of asthma?
- Commonly starts in childhood between the ages 3-5 years and may either worsen or improve during adolescence
- Peak prevalence between 5-15 years
- more common in developed countries
245
ASTHMA
what are the environmental factors for asthma?
* Early childhood exposure to allergens and maternal smoking has a
major influence on IgE production
* Growing up in a ‘clean’ environment may predispose towards an IgE
response to allergens whereas growing up in a ‘dirtier’ environment may
allow the immune system to avoid developing allergic responses
246
ASTHMA
what are the risk factors for developing asthma
- Personal history of atopy
- Family history of asthma or atopy
- Obesity
- Inner-city environment
- Premature birth (low birth weight, not breast-fed)
- Socio-economic deprivation
- exposure to allergens
247
ASTHMA
which drugs can trigger asthma attacks?
NSAIDs and aspirin
| beta blockers - results in bronchoconstriction which results in airflow limitation and potential attack
248
PHARMACOLOGY
give 2 examples of SABAs
- salbutamol (partial agonist)
| - terbutaline
249
PHARMACOLOGY
what is the mechanism of action for SABAs?
- are beta-2 selective
| - bind to B2 receptor causing more cAMP which leads to more bronchodilation
250
PHARMACOLOGY
how long do SABAs last for?
4 hours
251
PHARMACOLOGY
give 2 examples of LABAs
- salmeterol
| - formoterol (full agonist)
252
PHARMACOLOGY
what is the mechanism of action for LABAs?
- are beta-2 selective
- bind to B2 receptor causing more cAMP which leads to more bronchodilation
- are longer acting since more lipophilic so remain in the body for longer
253
PHARMACOLOGY
give an example of a SAMA
ipratropium
254
PHARMACOLOGY
what is the mechanism of action for SAMA?
- Act on airway M3 receptors
| - prevent ACh from binding since they bind to the M3 receptor thereby blocking ACh action
255
PHARMACOLOGY
give an example of a LAMA
tiotropium
256
PHARMACOLOGY
what is the mechanism of action for LAMA?
- Act on airway M3 receptors
- prevent ACh from binding since they bind to the M3 receptor thereby blocking ACh action
- has high affinity and disassociates slowly from muscarinic receptors
257
PHARMACOLOGY
what is the mechanism of action for ICS?
- They reduce the number of inflammatory cells in the airways
- Suppress production of chemotactic mediators
- Reduce adhesion molecular expression
- Inhibit inflammatory cell survival in the airway
- Suppress inflammatory gene expression in airway epithelial cells
258
PHARMACOLOGY
what are the side effects of ICS?
Loss of bone density
Adrenal suppression
Cataracts
Glaucoma
259
PHARMACOLOGY
what is the effect of interaction between beta-2 agonists and glucocorticoids in the treatment of asthma?
- glucocorticoids increase the transcription of B2-receptor gene, resulting in increased expression of cell surface receptors
- Long acting B2 agonists increase the translocation of GR from cytoplasm to the nucleus after activation by glucocorticoids
- Leads to greater overall efficacy and need for lower doses
260
PHARMACOLOGY
what are the advantages of inhaled drugs?
- lungs are robust -> can handle repeated exposure
- very rapid absorption
- large SA
- fewer drug metabolising enzymes
- non-invasive port of entry
- fewer systemic side effects
261
TB
what is a Ghon complex?
Ghon focus + lymph nodes
262
LUNG CANCER
what are the extra-pulmonary manifestations of lung cancer?
Recurrent laryngeal nerve palsy - hoarse voice
Superior vena cava obstruction - facial swelling, distended veins in neck and upper chest, Pemberton’s sign
Horner’s syndrome - ptosis, miosis, anhidrosis
263
ASBESTOS-RELATED LUNG DISEASE
what is it?
exposure to asbestos is though to result in macrophage + neutrophil activation
chronic inflammation causes DNA damage, increasing the risk of cancer
264
ASBESTOS-RELATED LUNG DISEASE
what is the spectrum of conditions?
- pleural plaques
- pleural thickening
- asbestosis
- mesothelioma
- lung cancer
265
ASBESTOS-RELATED LUNG DISEASE
what are pleural plaques?
benign
do not undergo malignant change
most common form of asbestos-related lung disease
often detected on CXR as incidental finding
266
ASBESTOS-RELATED LUNG DISEASE
what is pleural thickening?
diffuse thickening with similar pattern to haemothorax or empyema
267
ASBESTOS-RELATED LUNG DISEASE
what is asbestosis?
- restrictive lung disease
- lower lung zones affected predominantly
- severity is related to length of exposure
- presents with dyspnoea + reduced exercise tolerance
268
ASBESTOS-RELATED LUNG DISEASE
what is mesothelioma?
- malignant disease of pleura
- can occur with only short term exposure to asbestos
269
ASBESTOS-RELATED LUNG DISEASE
what is the management?
it has most often metastasised by diagnosis so most are inoperable
chemotherapy +/- radiotherapy
270
PNEUMOCONIOSIS
what is it?
interstitial lung disease secondary to occupational exposure causing an inflammatory reaction
271
PNEUMOCONIOSIS
what is the pathophysiology?
- when dust particles are inhaled, they reach terminal bronchioles + are ingested by interstitial + alveolar macrophages
- dust particles are carried by macrophages + expelled as mucus
- if exposed for a long time these systems no longer function
- macrophages accumulate in alveoli resulting in immune system activation + lung tissue damage
272
PNEUMOCONIOSIS
what are the different types?
- coal workers pneumoconiosis (coal miners)
- silicosis (quarry workers, silica miners)
- berylliosis (aerospace industry, beryllium miners)
- asbestosis (construction workers, plumbers)
273
PNEUMOCONIOSIS
what are the risk factors?
- male
- increasing age
- substance exposure
274
PNEUMOCONIOSIS
what are the symptoms?
SIMPLE PNEUMOCONIOSIS
- asymptomatic
PROGRESSIVE MASSIVE FIBROSIS
- exertional dyspnoea
- dry cough
- wheezing
- haemoptysis
- weight loss
275
PNEUMOCONIOSIS
what are the clinical signs?
- fine crackles
- wheezing
- clubbing
276
PNEUMOCONIOSIS
what are the investigations?
- CXR - opacities in upper lobes, eggshell calcification of hilar lymph nodes
- SPIROMETRY - restrictive pattern (FEV1/FVC>0.7)
- HIGH RESOLUTION CT CHEST - interstitial fibrosis
277
PNEUMOCONIOSIS
how is it staged?
using CXR
- 0 = small rounded opacities absent
- 1 = small rounded opacities but few in number
- 2 = numerous small rounded opacities but normal lung markings
-3 = numerous small rounded opacities + obscured lung markings
278
PNEUMOCONIOSIS
what is the management?
- smoking cessation
- avoidance of exposure
- pulmonary rehab
- supplementary oxygen
- corticosteroids
- lung transplant
279
HYPERSENTIVITY PNEUMONITIS
what is it?
type III + IV hypersensitivity reaction to an environmental allergen
280
HYPERSENTIVITY PNEUMONITIS
give some examples of causes
- bird fanciers lung (bird droppings)
- farmers lung (mould spores in hay)
- mushroom workers lung (mushroom antigens)
- malt workers lung (mould on barley)
281
HYPERSENTIVITY PNEUMONITIS
what is the pathophyisology?
type III + IV hypersensitivity reaction to environmental allergen
inhalation of allergens in patients sensitised to allergen causes an immune response
leads to inflammation + damage to lung tissue
282
HYPERSENTIVITY PNEUMONITIS
what are the symptoms?
- SOB
- cough
- chest tightness
- fatigue
283
HYPERSENTIVITY PNEUMONITIS
what are the investigations?
- bronchoalveolar lavage = raised lymphocytes
284
HYPERSENTIVITY PNEUMONITIS
what is the management?
- removal of allergen
- oxygen
- corticosteroids
285
RESPIRATORY FAILURE
what is it?
when the respiratory system fails to maintain adequate gas exchange, resulting in hypoxia and/or hypercapnia
286
RESPIRATORY FAILURE
what are the different types of respiratory failure?
type 1 = low O2 (hypoxia) + normal/low CO2
type 2 = low O2 (hypoxia) + raised CO2 (hypercapnia)
287
RESPIRATORY FAILURE
what is the pathophysiology of type 1 respiratory failure?
- due to problem with gas exchange between alveoli + blood
- typically due to V/Q mismatch
- oxygen predominantly affected due to ow blood solubility
288
RESPIRATORY FAILURE
what are the causes of type 1 respiratory failure?
- pneumonia
- heart failure
- asthma
- PE
- high altitude pulmonary oedema
289
RESPIRATORY FAILURE
what is the pathophysiology of type 2 respiratory failure?
- failure of adequate alveolar ventilation
- due to reduced respiratory drive, reduced compliance of lungs, increased airway resistance or muscle weakness
- impairs delivery of O2 + removal of CO2 from lungs
290
RESPIRATORY FAILURE
what are the causes of type 2 respiratory failure?
- opiate toxicity
- iatrogenic
- neuromuscular disease (MND, GBS)
- reduced chest wall compliance (Obesity)
- increased airway resistance (COPD)
291
RESPIRATORY FAILURE
what are the risk factors?
- chronic lung disease
- acute lung injury
- neuromuscular disorders
- chest wall deformities
- obesity hypoventilation syndrome
292
RESPIRATORY FAILURE
what are the symptoms?
- dyspnoea
- fatigue
- altered mental status
- orthopnoea
293
RESPIRATORY FAILURE
what are the clinical signs?
- tachypnoea
- wheezing
- cyanosis
- use of accessory muscles
294
RESPIRATORY FAILURE
what are the investigations?
- ABG
- CXR
- pulmonary function tests
- ECG
- echo
295
RESPIRATORY FAILURE
what is the management for type 1 respiratory failure?
- treat underlying cause
- oxygen therapy
- PEEP through CPAP
296
RESPIRATORY FAILURE
what is the management for type 2 respiratory failure?
- treat underlying cause
- oxygen therapy
- lower oxygen sats threshold (88-92%)
- NIV
- invasive mechanical ventilation
297
INFLUENZA
what is it?
acute viral respiratory infection caused by RNA viruses
298
INFLUENZA
what are the different types?
- influenza A = most virulent + responsible for outbreaks
- influenza B = less severe illness
- influenza C = mild/asymptomatic infection
299
INFLUENZA
what is the pathophysiology?
- virus invades + replicates in epithelial cells lining upper + lower resp tract
- localised inflammation + immune reaction causes resp symptoms + systemic symptoms
300
INFLUENZA
what are the risk factors?
- close proximity to infected persons
- age >65
- immunocompromised
301
INFLUENZA
what are the symptoms?
- SOB
- coryza
- cough
- fever
- myalgia
- GI disturbance
302
INFLUENZA
what are the clinical signs?
- raised respiratory rate
- rhinorrhoea
- reduced air entry or crackles on auscultation
- pyrexia
303
INFLUENZA
what are the investigations?
- nasopharyngeal swab
304
INFLUENZA
what is the management?
- not treatment required for majority
- if at risk or have severe flu, offer anti-virals (zanamivir, oseltamivir)
305
ASTHMA-COPD OVERLAP SYNDROME
what is it?
when patients have features of both asthma and COPD
are found to have airflow limitation that is not completely reversible after bronchodilation
306
ASTHMA-COPD OVERLAP SYNDROME
what are the symptoms?
same as asthma/COPD
- SOB on exertion
- can have diurnal variation
- cough
- wheeze
307
ASTHMA-COPD OVERLAP SYNDROME
what is the management?
manage as asthma until further investigations are performed
308
ACUTE BRONCHITIS
what is it?
It is a self-limiting lower respiratory tract infection
Infection + inflammation in bronchial airways
309
ACUTE BRONCHITIS
what are the causes?
- viral infections (coronavirus, rhinovirus, RSV, adenovirus)
310
ACUTE BRONCHITIS
what are the symptoms?
- cough (may or may not be productive)
- sore throat
- rhinorrhoea
- wheeze
- low grade fever
SIGNS
- no focal chest signs
311
ACUTE BRONCHITIS
what are the investigations?
clinical diagnosis
can consider following tests to rule out other causes
- pulmonary funciton test
- CXR
- bloods - CRP
312
ACUTE BRONCHITIS
what is the management?
- analgesia
- good fluid intake
- antibiotics (DOXYCYCLINE (or AMOXICILLIN if contraindicated))
consider antibiotics if:
- systemically unwell
- have pre-existing co-morbidities
- delayed abx prescription if CRP 20-100
- immediate abx if CRP >100
313
HYPERSENSITIVITY
what is it?
when the immune system over-responds to harmless antigens that result in harm to the body.
314
HYPERSENSITIVITY
what is a type 1 hypersensitivity reaction?
Classical allergy, mediated by the inappropriate production of specific IgE antibodies to harmless antigens
mast cells are activated + release histamine
315
HYPERSENSITIVITY
give some examples of type 1 hypersensitivity?
- anaphylaxis
- food allergy
- asthma
- hayfever
- allergic rhinitis
316
HYPERSENSITIVITY
what is type II hypersensitivity?
Caused by IgG and IgM antibodies that bind to antigens cells or tissues leading to cell or tissue damage
317
HYPERSENSITIVITY
give some examples of type II hypersensitivity reactions
- blood transfusion reactions
- haemolytic disease of the newborn
- goodpastures disease
318
HYPERSENSITIVITY
what is a type III hypersensitivity reaction?
Caused by antibody-antigen complexes being deposited in tissues, where they activate the complement system and cause inflammation
319
HYPERSENSITIVITY
give some examples of type III hypersensitivity reactions
- rheumatoid arthritis
- farmers lung (hypersensitivity pneumonitis)
320
HYPERSENSITIVITY
what is a type IV hypersensitivity reaction?
A delayed type hypersensitivity reaction caused by T helper cells traveling to the site of antigens, recruiting macrophages and causing inflammation
321
HYPERSENSITIVITY
give some examples of type IV hypersensitivity reactions
- poison ivy
- nickel and gold
- mantoux test
- TB
- graft vs host disease
- pneumoconiosis
- MS
- GBS
322
ANAPHYLAXIS
Exposure to an allergen causes the susceptible individual to form specific IgE antibodies.
Subsequent exposure leads to IgE -mediated activation and degranulation of mast cells , whilst basophils release inflammatory mediators such as histamine, prostaglandins, and leukotrienes
This results in rapid vasodilation and an increase in vascular permeability causing leakage of fluid out of the intravascular compartment.
this leads to cardiovascular collapse , sometimes referred to as anaphylactic shock. Additionally, bronchospasm and mucous membrane secretion result in respiratory distress and life-threatening laryngeal oedema
323
ANAPHYLAXIS
what are the symptoms?
angioedema (swelling to mouth, face, tongue and larynx)
- stridor
- wheeze
- pruritus + rash
- dizziness
- syncope
324
ANAPHYLAXIS
what are the signs of anaphylaxis?
- hypotensive
- tachycardic
- tachypnoea
- urticarial rash
325
ANAPHYLAXIS
what are the investigations?
- mast cell tryptase immediately, 1-2 hours post reaction + 24 hrs post-reaction
additional reaction
- skin prick test
- patch test
- challenge test
326
ANAPHYLAXIS
what is the management?
- IM adrenaline 500 micrograms
- give high flow O2
- antihistamine (chlorphenamine or cetirizine)
if no response after 5 mins repeat IM adrenaline + IV fluid bolus
no improvement after 2 doses of IM adrenaline = refractory anaphylaxis
327
ANAPHYLAXIS
what is the management of refractory anaphylaxis?
- start adrenaline IV (1mg adrenaline in 100ml 0.9% saline)
- rapid IV fluid bolus
328
ANAPHYLAXIS
when can patients be discharged?
AFTER 2 HOURS
- good response (within 5-10 mins) to single IM adrenaline
- complete resolution of symptoms
- has autoinjector + trained
AFTER 6 HOURS
- 2 doses of IM adrenaline
- previous biphasic reaction
AFTER 12 HOURS
- severe reaction (>2 doses IM adrenaline)
- severe asthma
- possibility of continued exposure to allergen
- presents at night or in area difficult to access in emergency
329
COVID-19
what causes it?
caused by corona-virus SARS-CoV-2
330
COVID-19
how is it spread?
via respiratory droplets
331
COVID-19
what are the factors that increase the risk of mortality?
- hypertension
- diabetes
- cardiovascular disease
- COPD
- cancer
- advancing age
332
COVID-19
what are the clinical features?
SYMPTOMS
- fatigue
- dry, persistent cough
- sputum production
- SOB
- myalgia
- chills
- N+V
SIGNS
- fever
- conjunctival congestion
333
COVID-19
what is the incubation period?
5-6 days before symptoms develop
334
COVID-19
what are the different levels of severity?
mild-moderate = all lab-confirmed cases
severe = dyspnoea, tachypnoea, sats <93%
critical = respiratory failure, septic shock, multi-organ failure
335
COVID-19
what are the investigations?
- PCR test
- sputum culture
- FBC
- cardiac markers
- coagulation
- CXR
to consider
- CT chest
- rapid lateral flow test
336
COVID-19
what is the management?
most do not require hospital and get better with self-care
1st line
- oxygen
- IV fluids
- dexamethasone
other options
- ITU referral
- ventilatory support
337
COVID-19
what public health interventions have helped to limit the spread?
- limit social contact
- vaccinations (Pfizer, astrazeneca)
338
URTI
what is it?
- usually a viral infection that causes inflammation of the upper airways
- referred to as 'cold'
339
URTI
what are the causes?
coronaviruses
adenoviruses
enteroviruses
RSV
metapneumovirus
influenza
340
URTI
how are they transmitted?
either by droplets or by direct contact with infectious secretions
341
URTI
what are the clinical features?
coryza
sneezing
cough
sore throat
low-grade fever
malaise
headache
hoarse voice
conjunctival injection
342
URTI
what are the investigations?
clinical diagnosis
PCR tests for COVID/flu
343
URTI
what is the management?
symptomatic relief
- fluid intake
- rest
- vapour rubs
- inhaling steam
- lozenges
- simple analgesia (paracetamol/ibuprofen)
